Neurosurg Focus 16 (1):Article 2, 2004, Click here to return to Table of Contents History of spine surgery in the ancient and medieval worlds JAMES TAIT GOODRICH, M.D., PH.D. Leo Davidoff Department of Neurological Surgery, Albert Einstein College of Medicine, Children’s Hospital of Montefiore, Bronx, New York There is a paucity of surviving texts from ancient and medieval times that can shed light on the early development of spine surgery. Nevertheless, the author reviews many of the available books and fragments and discusses early de- velopments in the field of spine surgery from the point of view of physicians’ personalities, general themes, and actu- al surgical practices. For purposes of an overview and to highlight changing trends in spine surgery, he divides the pa- per into four eras of medicine: 1) Egyptian and Babylonian; 2) Greek and early Byzantine; 3) Arabic; and 4) medieval. The early development of surgery of the spine is rather trends in spine surgery over the entire period, I have divid- sparse from the point of view of literature. Very few writ- ed this paper into the following eras: 1) Egyptian and ings from the ancient world have survived. Ancient med- Babylonian medicine, the embryonic period; 2) Greek icine, compared with its modern successor, lacked several and early Byzantine medicine, the historical origins of essentials such as an understanding of anatomy, recogni- spine surgery; 3) Arabic medicine, the prescholastic peri- tion of the concept of disease, and comprehension of the od; and 4) medieval medicine, the period of medical scho- origin of illness in an organic system. The failure to grasp lasticism. these vital principles retarded the practice of medicine and of surgery itself. The practice of neurosurgery and surgery of the spine did not really develop as a discrete EGYPTIAN AND BABYLONIAN MEDICINE: specialty until the 20th century. Despite these limitations I THE EMBRYONIC PERIOD will review some of the existent materials that deal with The Egyptian period encompasses approximately 30 the development of spine surgery in ancient and medieval successive dynasties and holds the claim to have pro- worlds.20 duced the earliest known practicing physician, Imhotep, For the ancient physician, the fear of operating was a who lived in the 14th century BC. For the modern scholar real one, especially when one had to deal with the central interested in studying medical and surgical material from nervous system. Two centuries before the birth of Christ, this epoch, there are only three existing documents that King Hammurabi of Babylon (1955–1912 BC) introduced have any relevance. These are the Ebers, Hearst, and a set of equitable laws that dealt with matters of everyday Edwin Smith papyri, which are discussed later in this life such as marriage, slavery, land purchase, and, of paper.6,9,15,16 course, medicine. The penalties established in this codex We know that anatomical dissection was performed for making surgical errors led surgeons in that period to during this period, but an examination of Egyptian papyri approach patients with some trepidation. In Hammurabi’s also show that the practice of medicine was largely based Code there are nine paragraphs devoted to the physician; on magic and superstition.41 Therapeutic measures de- one in particular deals with the operator who carries a pended on simple principles, most of which allowed na- bronze knife (scalpel) for wound care: ture to provide restoration of health with little interven- If a physician makes a wound and cures a freeman, he shall tion. In cases of injury Egyptian physicians realized that receive ten pieces of silver, but only five if the patient is the immobilization was important and prescribed splints for son of a plebeian or two if he is a slave. However it is decreed that purpose. Their materia medica was impressive, as that if a physician treats a patient “with a metal knife for a shown by their substantial pharmacopeias. severe wound and has caused the man to die—his hands shall Written approximately 500 years after the time of Ham- be cut off” (Code of Hammurabi). murabi, and the oldest medical text believed to exist In this paper I will discuss early developments in the (including ~ 107 pages of hieratic writing), the Ebers pa- field of spine surgery from the point of view of personal- pyrus, is interesting because of its advocacy of surgical ities, themes, and actual surgical practice as revealed in lit- practice. It contains a description, for example, of the re- erature surviving from ancient and medieval worlds. For moval of tumors and recommends surgical drainage of ab- purposes of an overview and to highlight the changing scesses.6 Neurosurg. Focus / Volume 16 / January, 2004 1 Unauthenticated | Downloaded 09/27/21 12:25 PM UTC J. T. Goodrich The Edwin Smith papyrus, written after 1700 BC, dur- tebra of his neck, and he suffers with stiffness in his neck. An ing the time of the New Kingdom, is considered to be the ailment with which I will contend.” oldest book on surgery per se; it comprises a papyrus Treatment: Thou shouldst bind it with fresh meat the first scroll measuring 15 ft in length and 1 ft in width. A total day. Now afterward moor [him] at his mooring stakes until the period of his injury passes by. of 48 cases are discussed in this document, including ones Case Thirty: Sprain in a cervical vertebra. Examination: If in which there were injuries to the spine and cranium. thou examinest a man having a sprain in a vertebra of his neck, Each case includes a diagnosis followed by a formulated thou shouldst say to him: “look at thy two shoulders and thy prognosis. Owing to the scholarly work of James Breas- breast.” When he does so, the seeing possible to him is painful. ted, this papyrus has been translated from the original, Diagnosis: Thou shouldst say concerning him: “One having which is in the possession of the New York Historical a sprain in a vertebra of his neck. An ailment which I will Society, and has been published in a limited edition.9 treat.” Aside from isolated cases found in these remaining pa- Treatment: Thou shouldst bind it with fresh meat the first day. Now afterward thou shouldst treat with honey every day pyri fragments, little can be gleaned from them on the until he recovers. actual practice of surgery and, in particular surgery of the Case Thirty-One: Dislocation of a cervical vertebra. spine. Rather than a direct surgical approach, most authors Examination: If thou examinest a man having a dislocation in a argued for stabilization and allowing nature to run its vertebra of his neck, shouldst thou find him unconscious of his course.15 It is evident from these writings that the Egyptian two arms and his two legs on account of it, while his phallus is physician recognized spine injury to be a most serious erected on account of it, and urine drops from his member problem with an outcome that was almost always fatal. In without his knowing it; his flesh has received wind; his two this section I will review several cases detailed in the Ed- eyes are bloodshot; it is a dislocation of a vertebra of his neck win Smith Papyrus that deal with spine injury. extending to his backbone which causes him to be unconscious of his two arms and his two legs. If, however, the middle verte- Edwin Smith has variously been described as an adven- bra of his neck is dislocated, it is an emissio seminis which turer, money lender, dealer and forgerer of antiquities, pio- befalls his phallus. neer in the study of Egyptian science, and a man of “great Diagnosis: Thou Shouldst say Concerning Him: “One hav- intellectual gifts.”9,15 In 1862 Smith, while in Luxor, ac- ing a dislocation in a vertebra of his neck, while he is uncon- quired the papyrus under controversial circumstances. Al- scious of his two legs and his two arms, and his urine dribbles. though some scholars believe that Smith legitimately pur- An ailment not to be treated.” chased the scroll from an Egyptian businessman named Case Thirty-Three: A crushed vertebra in his neck. Mustafa Agha, others claim that he bought it illegally Examination: If thou examinest a man having a crushed verte- from unscrupulous tomb raiders.9 Regardless of the meth- bra in his neck and thou findest that one vertebra has fallen into the next one, while he is voiceless and cannot speak; his falling ods by which he obtained the manuscript, Smith recog- head downward has caused that one vertebra crush into the next nized its importance and made efforts toward a first trans- one; and shouldst thou find that he is unconscious of his two lation. The papyrus remained in Smith’s possession until arms and his two legs because of it. (Conclusion follows in his death in 1906, after which his daughter donated it to diagnosis). the New York Historical Society. No further inquiry was Diagnosis: Thou Shouldst say Concerning Him: “One hav- made into the secrets of the papyrus until 24 years later ing a crushed vertebra in his neck; he is unconscious of his two when it was “rediscovered” and turned over to James arms (and) his two legs, (and) he is speechless. An ailment not Henry Breasted, an American Egyptologist and archeo- to be treated.” logist. Case 48: A sprain of a spinal vertebra (incomplete). Examination: If thou examinest (a man having) a sprain in a Although the papyrus reveals ancient Egyptian knowl- vertebra of his spinal column, thou shouldst say to him: edge about the heart and its relationship to the pulse, as “Extend now thy two legs (and) contract them both again.” well as functions of the stomach, bowels, and vascular When he extends them both he contracts them both immediate- system, the majority of the cases in the text concern top- ly because of the pain he causes in the vertebra of his spinal ics of neurosurgical interest.